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Billing for autism services starting January 1, 2019
November 30, 2018

This article is intended for providers who offer applied behavior analysis to our members.

As we communicated in our October 23, 2018 News Alert, codes for applied behavior analysis will change on January 1, 2019. As a result:

  • You no longer will be reimbursed separately for program planning (code G9012).  CPT codes 97155, 97156, 97157, and 97158 have been calculated to include a component for program planning. You can review these codes in addition to other covered applied behavior analysis codes on your fee schedule.
  • You should bill for initial assessment (97151) and re-assessment (97151 with modifier 52) on the date the service is rendered, not when the assessment has been completed. This change in billing is due to the new code description that notes “each 15 minutes."
  • We have added codes 0362T and 0373T to the fee schedule effective for dates of services on or after January 1, 2019. Bill for these codes under the NPI of only one licensed applied behavioral analyst with the total number of units. We will not provide separate reimbursement for CPT code 97155.

To view your News Alert, log in and go to News>Claims, Coding, Payment. Scroll down to the October 23 News Alert. To view your fee schedule, log in and go to Office Resources>Billing and Reimbursement>Fee Schedules.

Autism payment policy reminders
As our Autism payment policy notes, when billing for time-based codes, patient care must be provided for at least 50% of the time unit. In other words, a provider may only bill for services measured in 15 minute increments if they have provided 8 minutes of service.

In the autism payment policy and future communication, please note that we will use the term “behavior technician” instead of “paraprofessional”.

Please be sure that you maintain appropriate documentation that supports your billing for all applied behavior analysis services.

In January, we will update our process for prior authorization. The new Applied Behavior Analysis Services Request Form includes a section to request initial authorizations. For initial authorizations only, please call our Case Creation area at 1-800-524-4010, option 4 before submitting the form.

Your authorization process for ongoing services will not change. After you have submitted the Applied Behavior Analysis Service Request Form, we will call you to provide the authorization number and number of visits/days authorized by CPT code. You will also receive letters that provide the number of days of service authorized for licensed applied behavioral analyst and behavior technician services, and the number of units authorized for assessment/re-assessment services.